Frauds in Insurance:  Fake Documents for Annual Health Checkup (AHC) claim and  Rebating

Case Summary:

 Agents and diagnostic centers (herein after referred to as “Labs”) were found involved in making fraudulent health insurance claims under one of the product offered by the Company  by submitting  forged health checkup reports. Customer actually did not availed the health checkup facility  and the amount of health checkup claim was indirectly passed back to the customer as a rebate on the policy, the fraudulent AHC claims were filed by agents against policies being sourced and customers in most of the cases were not even aware of such claims.

 This was highlighted to fraud investigation team and the team reviewed the lab reports for Pan India locations. They further did field investigation wherein they visited and interviewed the Labs and the Lab Owners/Managers, interviewed employees and Agents of the Company. Lot of documents, emails and watsapp chats were recovered from such employees, agents and lab managers.

 Investigation Findings:

 The Investigation team post doing data study & document reviews found out that the lab reports shared were forged or were created with the help of Labs in lieu of some financial benefits.  During investigation, it   was noticed that same ID, same report/result, same time stamp or same remarks were used in different lab reports submitted by agents.

 Investigation team further went to these locations and checked with Labs and customers, where anomalies observed. The team even met the agents under whom these fake reports were uploaded and found that softcopy of the lab reports were available with the agents and they were sharing forged path lab reports to file a health checkup claim from the Company.

 In few cases it was also seen that these agents were sharing details such as name and Policy number with each other or the lab owners for creating forged lab report and then uploading the same in the system while claim process.

 The Investigation team came to know that such customers never went for the health checkup in the said Labs or the Labs was multiple kilometers away from the customer address and it would not have been feasible for the customer to travel such long distance when they had options nearby their address.

Few customer also confirmed that they have never given their consent for the health checkup and have never gone for any health checkup in the said location for which we had the lab report.

Conclusion:

 Getting all the facts of the cases with proper evidences, the investigation team represented this case to the concerned internal committee. Post discussions and basis   all evidences the committee came to a decision to terminate all the agents/ employees involved in this misconduct and file Police Complaint against such fraudulent labs and delinquent agents/employees.

While these decisions were taken, the Company took certain preventive measures including only physical submission of AHC claims and rigor in claim processing. In future products AHC is available only as cashless facility and for that purpose the Company has tied up with large Lab aggregators like 1 mg, medi buddy, health assure etc.